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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 77;74m64Ev' 6a / `, ,� _ 0 Zoning Sta ; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip)) <br /> C3 5^3 G7/}- ,f3cGL e v''ac �i. 635 <br /> Varid Re triction;CSM <br /> HOME PHON CELL PHONE E- AIL ADDRESS c� (# ) <br /> cGir"Y2 30°s 60f-2J-C--/g 9 Pi- £CAh 6 /4 ' & Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTO AME <br /> r(,E4- , PRI(hi et7rt) Site Plan including location <br /> AGENT ADDRESS P/1-. ."--- CONTRACT R ADDRESS y� f well/septic <br /> (city,state,zip) (City,State,Zip) / Setbacks <br /> t4i-074. ��� <br /> PHONE PHONE ❑ Site Pla proval from <br /> to_ 323- I5 Z7 ppli le township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> tvuk, clea/- AIi 164v r 4s` t- oor plans to scale <br /> PROPERTY/LOCATION INFORMATION <br /> (http://accessdane.co.dane.wi.us/) Elevation of ro <br /> e PARENT PARCEL cl ER: CURRENT , ACREAG❑ PARCEL 0 ,J 4,/..e.,?O q , y <br /> NUMBER frontage draw o <br /> scale. <br /> TOWNSHIP: i SE TI A' <br /> I-1 n y �r 6 S e 1/4: S 1/41/4: Yv ❑ Drive permits <br /> ADDRESS: Q y , f^ ' /� <br /> (st ,county,t wn) <br /> CSM: co`\ vj LOT / SUIBDfIIVISSIION \^J�` BLOCK/LOT ❑ Sanit permits <br /> (p ic,private) <br /> PROPOSED PROJECT INFORMATION 1ar-- <br /> P- .T DESIPuON: 0\ <br /> This project is a new build' g or structure. <br /> ❑This project is an additio /alteration to an existing building or structure. . _ `X- <br /> SANITARY SERVICE: PERMIT NUMB " "" �'z <br /> ' .. fit.s �'+ <br /> LI SEWER SEPTIC _ B a;6R4S .412,;40:;,:l-w: <br /> HEIGHT IN FEET: / NUMBER OF$TORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: = i <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) w � -° <br /> BASEMENT: 1ST FLOOR: (cço O �"�< SL? 9 ® g <br /> 4, TOTAL,S��(QQUUARE'FFO�IOTAGE 4, 1," s� <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: r (�. " �C' $ .'i noo(Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑ s No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑ es ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Yes ❑ o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? D s No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (le a blank if none) <br /> 6. Is a location survey required? (see reverse) es ❑No ❑Don't know <br /> 7. Is this to correct a violation? Yes ❑No <br /> C <br /> APPLICATION MUST BE SIGNED <br /> 545112(4ioel (Continue on Back) —► —► —► <br /> 85 . <br />